Provider Demographics
NPI:1083673123
Name:LARSEN, STEVE MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:STEVE
Middle Name:MARK
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-1024
Mailing Address - Country:US
Mailing Address - Phone:254-865-8251
Mailing Address - Fax:
Practice Address - Street 1:1507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-1024
Practice Address - Country:US
Practice Address - Phone:254-865-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0466103TC2200X
TX36884103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36884OtherSTATE LICENSING BOARD
NV100503261Medicaid